Provider Demographics
NPI:1407126865
Name:PETTY, REBEKAH J (NP)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:J
Last Name:PETTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N TOWN EAST BLVD
Mailing Address - Street 2:SUITE 138-209
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4157
Mailing Address - Country:US
Mailing Address - Phone:214-537-7220
Mailing Address - Fax:
Practice Address - Street 1:1515 N TOWN EAST BLVD
Practice Address - Street 2:SUITE 138-209
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4157
Practice Address - Country:US
Practice Address - Phone:214-537-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX612188363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily